Random thoughts from a few cantankerous American physicians. All contributors are board certified. Various specialties are represented here. I do not know where this will lead but hope it will at least be an enjoyable read. All of the names mentioned in this blog are pseudonyms, the ages have been changed, and in half the cases the gender as well. All photographs are published with patient consent or are digitally altered to preserve anonymity. Trust us, we're doctors.

Emergency on-call coverage from specialist physicians is "unraveling" at hospitals across the country, according to a new study--and the crisis may be pushing beleaguered physicians out of emergency medicine and into alternative careers, some observers warned.

The on-call specialist shortage is resulting in delayed treatment, patient transfers, permanent injuries, and even death, cautions a study from the Center for Studying Health System Change, a nonpartisan policy research group in Washington.

While the problem is predominantly an issue for hospital emergency departments, it also is becoming a challenge for inpatients who need urgent specialty care, according to the report. The findings are based on 2007 data from 12 nationally representative communities: Boston; Cleveland; Greenville, S.C.; Indianapolis; Lansing, Mich.; Little Rock, Ark.; Miami; Northern New Jersey; Orange County, Calif; Phoenix; Seattle; and Syracuse, N.Y.

The picture is especially grim given the fact that overall ED utilization rates have risen by 7% in the past decade, from 36.9 to 39.6 visits per 100 people, according to the report. While insured people account for the vast majority of ED visits, "the proportion of visits by uninsured people is rising at a relatively higher rate," the study's authors wrote.

Citing a 2006 paper from the American College of Emergency Physicians, the study reported that 73% of emergency departments in the United States report inadequate on-call coverage by specialist physicians. In particularly short supply are orthopedic surgeons, neurosurgeons, plastic surgeons, trauma surgeons, hand surgeons, obstetrician-gynecologists, neurologists, and ophthalmologists. While an actual shortage of such physicians may sometimes be to blame, "physician unwillingness to take call appears to be a more pressing issue for many hospitals," the study authors stated.

Although unwillingness to accept on-call duty is largely influenced by quality of life issues, the requirement to provide on-call coverage has traditionally been mandated by hospitals under the Emergency Medical Treatment and Labor Act. However, many specialists are now shifting their practices away from the hospital setting, and are no longer obligated by medical staff privileges, noted the report's authors.

Many physicians also believe payment for on-call care is inadequate, especially when they are caring for uninsured patients. Specialists are also concerned that providing emergency care may increase their exposure to medical liability and drive up the cost of their malpractice premiums, according to the report.

Adverse patient outcomes may be the result of a lack of timely specialty care. One study found that 21% of patient deaths or permanent injuries related to ED treatment delays are attributed to lack of specialists' availability, noted the report. Complete lack of access to specialty care in some EDs is forcing either travel or transfer of patients. And for the physicians who continue to provide on-call coverage, increasing workload and decreasing morale may put patients further at risk.

"It's not a surprise that we're having this problem - it's a surprise to me that we have any on-call specialists at all," Dr. Todd Taylor, previously an emergency physician and speaker for the ACEP Council, said in an interview. Dr. Taylor left clinical medicine last summer to work in the computer industry, he said, because the risks of liability were more than he could justify.

Lack of optimal on-call coverage is what will ultimately "cripple" trauma and emergency care, agreed Dr. L. D. Britt, professor of surgery at the Eastern Virginia Medical School in Norfolk. "Some of the specialists are asking for unbelievably exorbitant fees to provide coverage, and hospitals are being held hostage. That's unsustainable for many hospitals - it's a major crisis," he said in an interview.

While Dr. Britt sympathizes with physicians' struggles with payment and liability issues, he believes the true bottom line is simply that obligations are being overlooked.

"It cannot be everyone saying, 'I can't do this.' Something has to give," Dr. Britt said. "Speaking for myself, I consider it my obligation to provide emergency coverage if I am on call. I know that's my responsibility--and I'm a chairman of a department. Some people can find ways out of it, but I'm saying we cannot have all those options out there."

In addition, high fees charged by specialists and paid by hospitals for on-call coverage are not justified based on the premise that on-call coverage increases a physician's liability exposure, he said. "Being on call doesn't give you more litigation than being in general surgery--that's well documented," he said.

Dr. Taylor disagreed.

"The literature is very clear that emergency care is one of the highest liability environments in health care," he said. "You only have to look at what's happened to emergency physician malpractice premiums relative to others not involved in emergency care. Mine almost doubled the last 3 years I worked."

For Dr. Taylor, it is these very liability risks that are at the root of the current on-call crisis. "The liability issue has become the overriding barrier to physicians being willing to put themselves at risk," he said. "Until and unless you solve the liability crisis in emergency care and health care in general, nothing else you do matters."

More troubling than the lack of emergency on-call specialists, Dr. Taylor added, is a shortage of emergency physicians. This newer phenomenon was reported last year in the 2007 Daniel Stern & Associates Emergency Medicine Compensation and Benefits Survey.

"This has applied to on-call specialists for years, but the phenomenon is now spreading to core emergency physicians, who are increasingly seeking alternative careers," Dr. Taylor said, noting that 30% of the study's respondents said they were considering leaving medicine because of the malpractice climate.

Most on-call specialists have a private practice outside of the emergency department - they don't need the ED - so it's not a big surprise they were the first to leave, he explained.

"But now that core emergency physicians, who were trained only to practice emergency medicine, are making the same choices, that should be a wake-up call," Dr. Taylor said. "That's what's different now compared to 2 or 3 years ago."

6 comments:

dr britt, quoted here on the 'doctors need to be on call more' side of the fence is a department chair at a medical school. what that means to the uninitiated is that he has a host of interns and residents working for him who are all paid less than minimum wage. i'm sure he does come in... when his interns and residents need him, and, if they are good and motivated, like i'm sure they are, they probably don't call him much.community docs are on their own and for him to make this statement is just fucking ridiculous.

At my former job, we lost all ophthalmology, oro-maxillofacial, and plastics coverage. We lost neurosurgery for 30 to 40% of the time. It was a joke to call it an emergency department.

At my current hospital, the hospital pays the neurosurgeons and trauma surgeons a small fortune to be on call. I do not know who else they pay or how much they are paid, but that's the only way to keep specialists on the call sheet.

I work for a large academic medical center and we serve as a specialty physician to physician consult service for many of the rural hospitals who lack specialty services. If the problems can't be solved via virtual consult, the patients must be transported long distances to get to us for treatment. I think that the risk to the patients in delaying treatment only contributes to the problem. That Chair must not be putting in the kind of on-call and consult hours our docs are- so he is clueless...

While I was in the ED of our Level-1-Trauma-Mega-Academic Hospital of Glory over the summer we definitely had more than a few patients that had to sit around until 6-7 AM waiting for the Uro/Ophtho/Plastics residents on-call to finish their pre-rounds coffee.

We did manage to get one of the Ophtho residents in at 10PM for a peds bb-gun vs. globe rupture that we had transfered in from the boonies, but she was none-too-happy about it.

Not exactly on topic, but this came in todays ACEP e-mail. Apparently the MA insurance law has dropped the number of people showing up for "free care" in the ED. Here's the link:

My dad, a conservative tax attorney, who voted for George McGovern in 1972 because he was pissed about Nixon visiting Red China and Russia, is a pinko-liberal lefty when it comes to Health Care. Whenever I complain about malpractice, or defensive medicine, he just says that I knew what I was getting into, which I did. He has GREAT insurance, but only recently got a primary care doc, preferring to pay the ER decuctible, which to his credit he rarely used. The funny thing is he would never come in at 3am for an emergency tax situation, even if he would get his $300/hr right then. He's got enough work from 9-5 to pay for everything. He needs his sleep and weekend to enjoy his toys. He bills done to the tenth of an hour too.